I believe the quality issue is the greatest threat to healthcare in our country. Apparently, there are millions of "experts" out there who know all the "facts" and have alll the answers. Newsweek knows which are the best hospitals and who are the best doctors. If our medical leaders fool themselves that thay will have any influence on that question, we will continue our rapid slide into oblivion; if the medical community does not stand up now and just say "No!", I fear it is too late. The politicians and their minion beancounters have a single overwhelming agenda; money. An army of healthcare extenders will be born who will assume control. I plan to have "Do not resuscitate" tatood on my chest.

11:27 am April 8, 2009

Peter E Balsam, MD wrote :

I believe the quality issue is the greatest threat to healthcare in our country. Apparently, there are millions of "experts" out there who know all the "facts" and have alll the answers. Newsweek knows which are the best hospitals and who are the best doctors. If our medical leaders fool themselves that thay will have any influence on that question, we will continue our rapid slide into oblivion; if the medical community does not stand up now and just say "No!", I fear it is too late. The politicians and their minion beancounters have a single overwhelming agenda; money. An army of healthcare extenders will be born who will assume control. I plan to have "Do not resuscitate" tatood on my chest.

11:39 am April 8, 2009

RenalMD wrote :

Groopman and Hartzband's analysis is spot on. While they discuss how harmful these government-initiated quality rules can be, they don't say why bureaucrats push them in the first place. Government is lobbied by Pharma, and "Patient Advocacy Groups" who just happen to be largely funded by Pharma.

Pharmaceutical industries and guideline writing organizations can profit greatly by forcing government to adopt a guideline as a "quality care rule". These rules usually demand more medications and more interventions - all on someone else's dime. Patient advocacy groups, like the NKF and AHA, write many of these guidelines using the experts Pharma has as consultants and speakers, and the AHA and NKF are in turn funded by the pharmaceutical industries most likely to profit from higher drug sales.

11:55 am April 8, 2009

war horse wrote :

A system that mandates controls and guidelines across the spectrum of patient care has to be flexible enough to revise those guidelines when they're proved faulty. Or maybe it should divide mandates into different categories. For example, no one would argue that handwashing decreases infections. But others, such as tight regulation of glucose, might be under a category such as "best thinking to date." What will harm care is putting guidelines into place and saying--"that's the way it is because it's too much trouble to change it." The whole point of science is that it is evolving, not stationary.

12:02 pm April 8, 2009

ResQuality wrote :

We are concerned about the quality of care at Resurrection Health Care hospitals in Illinois. Health care experts have given low ratings to Resurrection Health Care hospitals and both patients and employees have reported issues with patient safety. If you want the full story on the quality of care given at Resurrection facilities, visit our website (www.resquality.com). If you were a patient at a Resurrection Health Care hospital and would like to share your story, please email us at info@resquality.com.

12:13 pm April 8, 2009

HIT Insider wrote :

After the US spends and forces others to spend billions of dollarson HIT, studies will demonstate a higher death rate and adverse outcomes from the use of these machines. It is known now that CPOE machines are dangerous yet they are still being used and promoted by the US Government. The HIT industry is advising the government. The FDA and the Joint Commission should be notified of adverse outcomes by patients and doctors.

12:47 pm April 8, 2009

GovtGuy wrote :

Thoughtful leaders in business and health care recognize the value of quality outcomes data transparency. It informs purchase decisions, improves medical outcomes, helps prevent deaths, holds down costs, and is supporting the reduction of hospital-acquired infections (the ones you did NOT have when you entered the hospital but did have when you left). It is particularly shown to improve outcomes in cardiac bypass surgeries. Flexible guidelines for medical providers are not compromised by reliable accurate data - - in fact, data supports the development of useful guidelines!

1:04 pm April 8, 2009

William Rose wrote :

As usual, the debates about "quality of care" (I hate the term "health care" --it is demeaning to the consumer (I also hate the word "patient") and treatment options. These debates focus on M.D.'s vs insurance companies, government, other providers, etc. --as though those are the only important players. THE ONLY IMPORTANT PLAYER SHOULD BE THE PERSON SEEKING THE SERVICES. A revolution is underway -ignored by the usual players: thanks to the abundance of information and personal initiative, so-called "patients" are becoming informed and pro-active. They should decide these questions, based on a wide variety of sources, of which M.D.s are only advisors. It should not be up to M.D.s or anyone besides the consumer, to decide what is acceptable treatment or parameters for treatment, or no treatment. The quidelines should be guidelnes for individuals to consider --not "health care providers" or anyone else.

1:38 pm April 8, 2009

Risa Pendt wrote :

How can you really argue against quality measures? That's like saying we shouldn't have ingredient labels on food, because we don't want to know what's inside and take responsibility for our own health. I understand that physicians are wary of being held accountable and having their pay commensurate with quality and effectiveness, but that is no reason to stop quality measures. Sure, we need to make sure the measures are precise and effectively show strenghts and weaknesses. But I'm pleased to see a move toward greater measurement and transparency. This can only improve quality and affordability.

2:11 pm April 8, 2009

Jerod M. Loeb, PhD wrote :

The Joint Commission has been in contact with the Wall Street Journal and has requested a correction to factually inaccurate information in the Groopman and Hartzband op-ed appearing today. The fifth paragraph of the editorial is incorrect in stating that The Joint Commission adopted tight control of blood sugar as a suggested quality metric. The Joint Commission did not adopt such a measure.

Jerod M. Loeb, PhD
Executive Vice President for Quality Measurement and Research
The Joint Commission

2:20 pm April 8, 2009

Ray wrote :

washing hands cut infections, reducing calories will help lose weight, don't over precribe antibiotics as it causes resistance, all shown over and over in studies to improve otcomes. More good comes out of evidence medicine than not. Key is good studies and unbiased research is what we need to focus on. Medicine is art but there is plenty of bad art out there and evidence based medicine is the key to improve our standards. Patients are shocked when they hear that majority of doctors can not keep up with medical literature and patient has no way to assess his doctor's competence.

2:47 pm April 8, 2009

Lynn wrote :

For the last several months I have served as a "caregiver/decision-maker" for a dear friend with a terminal illness. I have observed excellent care, adequate care, and abysmal care all in the same healthcare institution. The difference is in the culture on each floor--mostly nursing care. There is a tangible quality commitment on the floors where my friend receive excellent care. Quality guidelines are a keystone to excellent care. Nurses have run the checklist and each time they have elected to deviate has been explain and documented. Guidelines are just that guidelines, a reference point. It is reassuring to have a physician pause and explain why she/he is doing something different. Stopping to think about quality is what is important but acknowledging professional skill and judgment is equally important.
Quality in healthcare is like the early days of auto seat belts until it becomes second nature and part of the culture we need to stop, think, and then proceed. So thanks to the caregivers who wash their hands and foam in and out!

3:21 pm April 8, 2009

SamiK wrote :

To paraphrase Warren Buffett, "It's better to be approximately right, then precisely wrong". Outside of public school education, there isn't an industry where employees aren't judged on some sort of performance evaluation (i.e. "Did you do your job well"). Why should doctors be the exception? I don't doubt that any metric can be gamed, abused etc. And while I think patient feedback is part of it, patients aren't the best judge of technical skill.

3:56 pm April 8, 2009

Bernard M. Rosof, MD wrote :

The op-ed by Groopman and Hartzband is right to urge great care in developing healthcare quality measures, but ignores the reality that some of the dramatic improvements in healthcare are the results of quality/performance measures. We can only improve what we can measure.

Measures allow us to see where we are now and make the changes that avoid medical errors, save lives, and create a race to the top that ensures world-class care no matter where you live. We know from more than 30 years of data in the Dartmouth Atlas that there is widespread variation in the quality of care in many common chronic conditions. We know that for certain chronic conditions there are things you should absolutely do. We have a very strong evidence base of what should be done in many areas like diabetes and cardiac conditions. However, a RAND study shows that less than 50 percent of people receive the care that the evidence base supports.

It is true that caution is advised in developing quality measures that are too narrow and rigid, particularly in the face of new findings. Quality metrics should not be static, but should be as dynamic as the changing evidence base in health care. This is quite possible to achieve.

We cannot and should not be satisfied that half of us are getting the right care at the right time. Quality metrics can light the way for more equitable, high quality care for every patient, every time they see their doctor or other healthcare providers. Now is not the time to roll back this progress.

3:56 pm April 8, 2009

Bernard M. Rosof, MD wrote :

The op-ed by Groopman and Hartzband is right to urge great care in developing healthcare quality measures, but ignores the reality that some of the dramatic improvements in healthcare are the results of quality/performance measures. We can only improve what we can measure.

Measures allow us to see where we are now and make the changes that avoid medical errors, save lives, and create a race to the top that ensures world-class care no matter where you live. We know from more than 30 years of data in the Dartmouth Atlas that there is widespread variation in the quality of care in many common chronic conditions. We know that for certain chronic conditions there are things you should absolutely do. We have a very strong evidence base of what should be done in many areas like diabetes and cardiac conditions. However, a RAND study shows that less than 50 percent of people receive the care that the evidence base supports.

It is true that caution is advised in developing quality measures that are too narrow and rigid, particularly in the face of new findings. Quality metrics should not be static, but should be as dynamic as the changing evidence base in health care. This is quite possible to achieve.

We cannot and should not be satisfied that half of us are getting the right care at the right time. Quality metrics can light the way for more equitable, high quality care for every patient, every time they see their doctor or other healthcare providers. Now is not the time to roll back this progress.

So, what are the physicians afraid of? Everyone wants "self-regulation" but that only works so far.

The larger issue for the Govt., in my opinion, is the "piece-meal" invoicing for treatments instead of one bill for the whole thing.

I understand that every patient has an individual manifestation of the disease, but evidence-based methods are necessary to prevent over-reaching on both sides of the fence.

5:37 pm April 8, 2009

Seattle ARNP wrote :

To those that fear "the quality issue is the biggest threat to health care", I would offer that health care decisions are based on evaluation of evidence - demonstrating effectiveness of newer methods compared with current standards... Why should the process of care delivery be subject to any less inspection? Without evidence, or metrics of performance, how can health care delivery improve?

Establishing valid and reliable measures of health care performance is clearly a difficult task, but an essential step in improving care delivery and safety for patients. One mechanism that obviously needs to be "built-in" to the system is a process for updating evidence-based guidelines and quality indicators as the science evolves. In addition to measuring, reporting and transparency about adherence to practice guidelines, health care organizations also need to look more closely at their processes for delivering care as a mechanism to ensure quality and safety. Identifying and reporting compliance with practices that reduce errors, provide decision support and improve communication (such as standardization of procedures, EMR use, computer-based ordering systems) - consumers of health care need to know not only that their providers are competent, but that the system which they are entrusting their care to is competent as well. Providers need to recognize that the desire to "individualize care" needs to be balanced with practices that create an environment of quality and safety for all patients. There is no "one size fits all", but identifying standards improves the likelihood of receiving appropriate care.

10:30 pm April 8, 2009

zman wrote :

Trying to improve healthcare delivery is a noble goal. It should be embraced. The problem is that in their rush to embrace 'quality improvement', a number of agencies, institutes, and centers have made recommendations regarding practice standards that have subsequently been shown to be wrong. Beta blockers, glycemic control, and pain management are just a few examples of where attempts to make things better has resulted in increased morbidity and mortality. As a result, the credibility of future recommendations will be viewed with skepticism. This is truly unfortunate. We need to hear some mea culpas from those groups that made these bad recommendations and a clear plan as to how they won't let it happen again.

10:43 pm April 8, 2009

NLiberty wrote :

The editorial by Groopman and Hartzband never disparages data, or data collection or measurement. Re-read the editorial if you think they decry measurement (all medicine is enthusiastically for measurement and metrics).

However, the doctors address the bureaucratic and rigid application of data to codify certain procedures, that become rigidly embedded in practice despite medical science moving forward with newer findings. Although the intent was to standardize procedures, the actuality is that often the 'quality guidelines' form rigid little rules where obsessive administrators develop fiefdoms and bureaucratic boondoggles to control people and enhance their own self-importance.

The JCAHO will scream about their regulations but if anyone has witnessed a JCAHO 'inspection' you realize it is an exercise in intense bureaucratic control that enhances the JCAHO coffers and the JCAHO power structure and strangle-hold on the big business of health care.

Clearly medicine needs to adhere to the guidelines that medical science offers in the journals; but it is unlikely the professional bureaucrats at the regulatory agencies will improve quality of medicine with their periodic self-important sorties that cost millions and disrupt hospitals.

Even if the JCAHO thinks they don't promote tight regulation of diabetes, some people believe they do:

Of course, doctors should be accountable for the quality of the care they provide. Of course, there is evidence based medicine. Of course, doctors should practice evidence based medicine. The trouble with evidence based medicine is that it is fluid, as Dr. Groopman pointed out in the original article on which this blog is based. Evidence thus requires the continuous attention of the reading physician. The conscientious physician can be much more on top of the literature than a guideline can be because he is a thinking being and not set on paper at a specific period of time.

Guidelines are overly simplified parameters of health care. They are an oversimplified interpretation of the evidence. The reality is that many guidelines are not really based upon real evidence. Rather, they are based upon the opinions of designated physicians.

They are also under the influence of all sorts of forces not all of which have the best interests of the patient at hand. There are insurance companies that do not want to pay for services. There are pharmaceutical and device companies that want to promote their products. There are physicians who want to promote their specialties and their procedures. There is all sorts of collusion since there are millions of dollars at stake. Guidelines would be much better and be more respected within the medical community, if all these pernicious influences were removed.

So, there is no reason to think that guidelines are better than the physicians or hospitals that they want to improve. They may be better than the mediocre are subpar physician. But that physician is not likely to read guidelines.

There are all sorts of ways of improving medical care and avoiding mistakes. Guidelines may be more wishful thinking or more window dressing for a system we are unwilling to reform.

1. Better selection of medical students. The reality is that the heavy indebtedness of our medical students is scaring away medical school applicants. There are 42000 applicants for about 18000 slots. If there were more than three candidates per slot, the average graduating doctor would be significantly more talented and better qualified and more representative of the general populations to be served.

2. If medical education were free, medical doctors would not have to learn and do procedures to pay back their loans. Procedures do serve to generate income.

3. If doctors could have more time per patient without the interference of procedures or devices, that would generate better rapport, attention to detail and avoid many misdiagnoses, miscommunications, etc. That is as true of the colonoscopy as it is true of the primary care visit.

4. Access to properly organized and appropriate medical information and supportive services (rather than form filling harassment or rigid guidelines) at the point of care could also go a long way. Simple prompts and reminders whether through reminders or check lists can reduce errors and improve patient safety. Appropriate supportive continuing medical education to support life long learning without conflict of interest could also be of help.

5. Having a workforce commensurate to our needs. The absence of primary care physicians results in patients going to doctors too late with problems that are more difficult to solve. Having patients going to emergency rooms or specialists results in almost by definition a poor and expensive clinical encounter with the exception of those cases that need immediate attention.

6. Universal health insurance. As a Canadian trained physician, I am always perplexed that America worries so much about the quality of the care of the insured but not of the absence of the care for the uninsured. It does not seem to bother people that we have uninsured children. Copayment fees are absent in Canada by law and patient can check on anything early on without worry of cost. In this country, the converse seems to be true. By having different standards of care for various segments of the population: Medicare, Medicaid, private insurance, community centers, and VA hospitals, we have fragmented our health care delivery and thus by definition eroded the standards of health care. We have, in effect, institutionalized Medicaid mills for the poor and are thus all paying the price with substandard care. Training in the inner city breeds cynicism among doctors.

7. As long as we have profit making insurance companies and quality insurance companies seeking to set the standard the care, cynicism will rein within our health care system. The solutions to our health care dilemmas and quality will remain elusive. There will simply be no widely respected standard of care.

Tullman is correct in informing Obama of the need for computers, computers, computers, computers, and more computers to automate medical care to assure each patient with a specific disease gets the "best" treatment for that disease. The only problem with that advice is that the computers are a disease and cause adverse outcomes. Which is the best HIT, which cause the fewest deaths, and who has determined that amy of these instruments are safe and effective? Just ask http://www.chitowndailynews.org/Chicago_news/Exclusive_Billing_glitch_led_to_mental_health_closures,24833 the Chicago mental health clinics
these clinics.

7:04 am April 9, 2009

Anne PME wrote :

The problem with iguidelines is that ithey may be used to skewer the weight away from the the most important medical evidence...the individual patients' evidence that is (or rather should be) accumulated and documented during a billable medical appointment time. WRT primary care, the medical evidence is usually best developed during the course of a long term physician patient relationship. These days, it seems as though the specialists pass off to the primary, the primary tries to pass off to the emergency room and/or pharmacist, and the pharmacists and emergency room pass off to outpatient and the insurance companies seem to exist to perpetuate dysfuntion. When you don;t take the time to uncover the actual problem...identify the problem(s), how can you possibly fix the problem correctly? When physicians like primary care physicians are focused on keeping their practice afloat by trying to see as many patients as possible and do as many procedures as possible; trying to figure out drug formularies; or trying to spoon people the insurance company radiation interrogators; they can and often do loose focus on the patient evidence. YOu see this in the younger physicians who use EMR here and in the physicians who have given up ...they don't review patient charts before or during an appointment and they no longer have the time or ability to qualify the patient properly...to talk with their patients and/or review and correct patient notes and labs.

7:46 am April 9, 2009

Julie Stansfield MD wrote :

“Quality Care” sounds like a nice label, but it isn’t really high quality care. Most states define a doctor patient relationship clearly to require a history and physical. The new fashion in “quality care” does not require either of these. Decisions are made from a computer remotely. The problem is studies are designed for specific populations, your patient may not fit that population at all. Daily I must struggle to explain these basic facts to non physicians. Patients may older than the study group, have many more diseases than the study group or have an unusual variant of a disease. People simply are not alike. Even something as simple as buying shoes requires different sizes, why can’t that same measure of quality be applied to medicine? It is a truly dangerous trend.

10:12 am April 9, 2009

skwerldoc wrote :

That article brings up a good point towards the end in regards to doctors dropping noncompliant patients. It wouldn't surprise me to see doctors either refusing to accept new patients with uncontrolled diabetes, firing patients with poorly controlled hypertension. Most of these measures are based on percentages, so it would be much easier for a doc to take on only 2 diabetic patients, get those two in control, and then it appears as if the doc has 100% diabetes control in his/her panel of patients. Most doctors are pretty smart. It wouldn't take long for them to figure out how to skew their numbers.

10:59 am April 9, 2009

HIT Guideline writer wrote :

Tullman is correct in informing Obama of the need for computers, computers, computers, computers, and more computers to automate medical care to assure each patient gets the government determined "best" and cheapest treatment for that disease.

The problem with that advice is that the computers are a disease and cause disease and adverse outcomes.

Which is the best HIT, which cause the fewest deaths, and who has determined that any of these instruments are safe and effective? The readers of this blog may be interested in the answers: no one knows and no one has determined S & E.

To see HIT in the real world, search the Chitowndaily news for the HIT glitches that closed numerous mental health clinics causing patient abandonment.

1. With all due respect to the "good doctors," there is no doctor accountability when the doctor screws up and screws up badly. The state based medical regulatory agencies generally protect the doctors. And, of course, the big lobbying organizations such as the AMA are there to protect bad doctors too.

2. What is up with the AMA and organizations such as the ABOS intimidating "good doctors" from testifying against "bad doctors" in court. The argument is that the "good doctors" are practicing medicine. Who the heck protects the patients.

3. And, IMHO, the Joint Commission MUST set standards for the generally rogue group of hospitalists that are typically protecting their turf and will not even contact the patients' treating physicians. My dad is 75 years and he has been actually injured by the arrogance of DUH hospitalists. (http://advocateyourself.blogspot.com)

4. There is absolutely no reason for the patients' medical records to be computerized beyond the clinic and related hospitals. Other than that the egotistical docs should pick up a damn telephone and actually have the guts to communicate directly with another doctor.

5. Universal healthcare and P4P will force the good docs absolutely out of clinic practice and into straight research. Canada can have it. We do not need it here. We need the reform of the current system. Including insurance companies and medical facilities stopping this insanity of "secret deals" where the patient has no clue of the charges. And, where the uninsured actually pay a premium for the medical care. That is nuts.

7. My experience in being an advocate for my elderly dad is that the current US medical system wants older patients to just plain die.

12:47 pm April 10, 2009

CWH MD wrote :

Quality is an " A Priori " concept, Is is not ? As Robert Pirsig explains in " Zen and the Art of Motorcycle Maintenance " Quality cannot be easily measured or defined because it empirically precedes any intellectual construction." It is the " knife edge " of experience. " Patients are not like food labels. Every patient is unique and some of them don't fit into nice, neat government evidence based practice protocols.

This brave article by Dr. Groopman and Hartzband is excellent. They did not discount the importance of evidence based practice. In fact they applauded it when it comes to undisputed evidence such as good handwashing. The danger comes when the government or insurance company abuses data to suit their agenda under the guise of " Quality. " In the case of these pilot projects by the federal government, the agenda was not to suit PHARMA, but to restrict payments to health care providers for services.

This is possibly a sign of things to come. Buzz words such as CER (Comparative Effectiveness Research) could be abused. Knowledge is fluid and takes time to accumulate. Lack of evidence doesn't always mean lack of benefit. What happens when your patient doesn't fit into that " pop " up category on the computer ? What is good for one population may not apply to your patient. For example, Oncology patients are often on ITP and Steroids for Lymphoma...their blood sugar may run a little high. Does that mean they received bad care? No-one will want to take care of sick patients anymore because their " numbers " will look bad. These days, most of the patients in the hospital aren't just there for well baby checks.

One last thought....what is wrong with the patient being an informed, educated consumer ? Sure patients don't have all the technical knowledge, but they aren't stupid. They need to be empowered to be active in their health care decisions....it should also be very clear to them what things cost. Doctors have a responsibility to stay informed by peer reviewed research and patients should ask about this. Patient satisfaction should also be part of the equation when measuring " Quality. " Tools for this could be tested for validity. A doctor who spends alot of time with their patient and establishes an effective doctor patient relationship does just as much, if not more to improve quality than a hastily defined parameter

6:10 pm April 10, 2009

anonMD wrote :

"There is a great deal of resistance to healthcare reform because industry players make so much money from the current system, said George Halvorson, chairman and CEO of the Kaiser Foundation Health Plan and Kaiser Foundation Hospitals." This is a quote from a speech given at the Healthcare Information and Management Systems Society's meeting this week in Chicago.

* Increases in Resurrrection Revenues, 2000-2007: 160%
* Decrease in non-management patient care salaries as a percent of Resurrection total revenue 2000-2007: - 40%
* Decrease in patient care supplies as a percent of Resurrection total revenue 2000-2007: - 51%
These figures are from the web site http://www.resquality.com, which is not sponsored by the hospital but is instead (apparently) put together by disgruntled insiders who perceive the quality of care to be slipping.

Corporate medicine is illegal in most jurisdictions in the United States, but the narrowness of the definition has allowed corporations to now openly debate and institute health care changes based on the profit motive rather than the patient's care. The first quote tells us why; the second tells us how.

Although neither quote is a definitive statement of the state of health care, both are indicative of how the doctors and nurses who actually provide that care see the system "evolving" (or not.) Corporations involved in health care delivery are all highly supportive of electronic medical record systems, but those of us on the front lines fear, with good reason, that the real goal of these systems is not to increase quality, but to increase profits by, in fact, cutting care, and cutting the salaries of those who provide it.

There is a huge potential benefit from the adoption of an electronic medical record, but there are several caveats. First and foremost, the patient must control access to their medical information, and it must never be accessed without the patien's explicit permission. Second, physicians must be protected from the current and growing use of EMRs by hospitals and insurers designed to force physicians, at the threat of their jobs, to reduce care delivery, or to provide care only according to the "one size fits all" criteria which today's article questions.

The issue of "economic credentialing" of medical professionals has been on the list of concerns for a number of years. It is clear that hospitals and insurers are engaging in the race to the EMR at least in part because they perceive it as a tool with which they can force physicians to do their bidding by increasing the data they can input into an economic credentialing process. This is an extremely dangerous trend.

10:44 pm April 10, 2009

Odette Batik MD MPH wrote :

I believe it very helpful to have access to truly evidence based guidelines. These should optimally be the result of high quality controlled clinical trials, or good population based studies such as Framingham. That having been said, the limits of EHR in measuring these for any individual physicians' practice have NOT been widely understood or acknowledged.
For any individual patient a given guideline may not apply due to another medical condition, may apply, but be impossible for the patient to comply with due to financial inability to afford the optimal therapy, and/or the patient may simply chose NOT to comply for any of a plethora of reasons that he or she has every right to decide. More problematic are those with mental health comorbidity so severe that wandering in the door in crisis one time is the best they can manage. EHR does not capture this variability, so for those physicians who like I, have chosen to serve a population of financially stressed. socially stressed and culturally diverse individuals, the care delivered will by nature of the denominator never compare to the statistics of a more advantaged population.

6:37 pm April 12, 2009

Anonymous wrote :

Guidelines are just that. GUIDELINES. If everyone notices, those pushing "guidelines" are the academic elites egged on by Political and Insurance interests. Those most accepting of guidelines are those with the least critical thinking and training. A patient does not fit neatly into an algorithm, much to the chagrin of these elites, who would just as well have your care automated and at best delivered by much less well trained practitioners in the name of cost containment.
We need to be vigilant about this, and jealously safeguard the autonomy of the medical profession, for we all collectively lose when this is trampled upon. Progress is not neat, nor cheap. Good quality healthcare likewise.
People must learn to accept certain inefficiencies in health care. Overtreatment is potentially more risky than undertreatment. The Hippocratic Oath always guides us to first "DO NO HARM". Loss of critical thinking and following an algorithm will lead to this. For those who say continue to think critically using an algorithm, that is like saying continue to exercise your quadriceps while driving a car.

4:44 pm April 13, 2009

scimitar wrote :

A cautionary tale about insurance companies, "quality care" and guidelines. Last year I was rated in the highest ( 3 stars, like the restaurants) category in a Unitedhealth Group quality program for primary care docs (quality and UHC - is that an oxymoron or what!). This year I found myself "demoted" to two stars. After much time spent in the UHC telephone labrynth searching for a 'qualified' human to speak with regarding the quality measures, I finally found someone who explained that I did not have enough patients with asthma to be measurable on their scales. But further questioning elicited the fact that their "physician quality measures" were based solely on the number of patients with asthma in their 'commercial" health plans. The measuring system excluded entirely any and all patients on Medicaid, of which I had several patients with asthma who would have met the "minimal patient number" requirements for analysis. So I questioned the UHC rep as to whether they assumed or intended that I should treat my Medicaid asthma patients enrolled in the State UHC managed care plan for Medicaid differently from their commercial
clients. No, of course not. Well then, why would that group not be counted as part of my overall care? No answer. The quality measures are just for 'commercial patients'.

The irony is that I treat my patients as individuals equally, whether on Medicaid managed care or Commercial managed care. They all get my unbiased care and expertise. Yet United dares to segregate their patients in judging my quality care based on their economic station. Does that raise a few eyebrows about what's going on in the board rooms of for-profit outfits with the modest moral quallity and integrity of Unitedhealth??